TX Clinical Judgement Practice Exam- Solved
Correct
Incorrect
1 of 135
Term
A young male client is admitted to rehabilitation following a right
above-knee amputation (AKA) for a severe traumatic injury. He is in the
commons room and anxiously calls out to the nurse, stating that his
"right foot is aching." The nurse offers reassurance and support. Which
additional intervention is most important for the nurse to implement?
Offer to assist the client to a quieter location so he can relax.
Teach the client how to wrap the stump with an elastic bandage.
Encourage discussion of feelings about the loss of his limb.
Administer a prescription for gabapentin, a neuroleptic agent.
Give this one a try later!
Administer the medication via the oral Titrate the dopamine infusion to raise
route as prescribed. the BP.
, Administer a prescription for
Attempt to distract the client with
gabapentin, a neuroleptic
general conversation.
agent.
Don't know?
2 of 135
Term
The nurse is planning care for a client who admits having suicidal
thoughts. Which client behavior indicates the highest risk for the client
acting on these suicidal thoughts?
Expresses feelings of sadness and loneliness.
Neglects personal hygiene and has no appetite.
Lacks interest in the activities of family and friends.
Begins to show signs of improvement in affect.
Give this one a try later!
Wear water shoes in the public Begins to show signs of
shower. improvement in affect.
Assess the client for self care ability.
Provide pain medication instructions. Position a firm wedge to support
Teach care of ostomy to care pelvis and thorax at 30 degree tilt.
provider.
Don't know?
, 3 of 135
Term
At 40-weeks gestation, a client who is in active labor is lying in a supine
position and tells the nurse that she has finally found a comfortable
position. What action should the nurse take?
Encourage the client to turn on her left side.
Place pillows under the client's head and knees.
Explain to the client that her position is not safe.
Place a wedge under the client's right hip.
Give this one a try later!
Had a cold and ear infection for the Reinforce need for adequate
past two days. hydration.
Consumes 3 meals and 1500 mL of Place a wedge under the client's
fluid per day. right hip.
Don't know?
4 of 135
Term
A client with chronic alcoholism is admitted with a decreased serum
magnesium level. Which snack option should the nurse recommend to
the client?
Cheddar cheese and crackers.
, Carrot and celery sticks.
Beef bologna sausage slices.
Dry roasted almonds.
Give this one a try later!
"You seem quite frightened right
Dry roasted almonds.
now."
Cinnamon applesauce. Decreased serum potassium.
Don't know?
5 of 135
Term
The nurse is planning care for a client with chronic kidney disease who
is a resident at a long-term nursing facility. The client is anuric and has
hemodialysis 3 times a week. Which intervention should the nurse
include in the client's plan of care?
Encourage intake of high potassium foods.
Provide perineal skin barrier cream.
Initiate toileting schedule.
Monitor for signs of anemia.
Give this one a try later!
Correct
Incorrect
1 of 135
Term
A young male client is admitted to rehabilitation following a right
above-knee amputation (AKA) for a severe traumatic injury. He is in the
commons room and anxiously calls out to the nurse, stating that his
"right foot is aching." The nurse offers reassurance and support. Which
additional intervention is most important for the nurse to implement?
Offer to assist the client to a quieter location so he can relax.
Teach the client how to wrap the stump with an elastic bandage.
Encourage discussion of feelings about the loss of his limb.
Administer a prescription for gabapentin, a neuroleptic agent.
Give this one a try later!
Administer the medication via the oral Titrate the dopamine infusion to raise
route as prescribed. the BP.
, Administer a prescription for
Attempt to distract the client with
gabapentin, a neuroleptic
general conversation.
agent.
Don't know?
2 of 135
Term
The nurse is planning care for a client who admits having suicidal
thoughts. Which client behavior indicates the highest risk for the client
acting on these suicidal thoughts?
Expresses feelings of sadness and loneliness.
Neglects personal hygiene and has no appetite.
Lacks interest in the activities of family and friends.
Begins to show signs of improvement in affect.
Give this one a try later!
Wear water shoes in the public Begins to show signs of
shower. improvement in affect.
Assess the client for self care ability.
Provide pain medication instructions. Position a firm wedge to support
Teach care of ostomy to care pelvis and thorax at 30 degree tilt.
provider.
Don't know?
, 3 of 135
Term
At 40-weeks gestation, a client who is in active labor is lying in a supine
position and tells the nurse that she has finally found a comfortable
position. What action should the nurse take?
Encourage the client to turn on her left side.
Place pillows under the client's head and knees.
Explain to the client that her position is not safe.
Place a wedge under the client's right hip.
Give this one a try later!
Had a cold and ear infection for the Reinforce need for adequate
past two days. hydration.
Consumes 3 meals and 1500 mL of Place a wedge under the client's
fluid per day. right hip.
Don't know?
4 of 135
Term
A client with chronic alcoholism is admitted with a decreased serum
magnesium level. Which snack option should the nurse recommend to
the client?
Cheddar cheese and crackers.
, Carrot and celery sticks.
Beef bologna sausage slices.
Dry roasted almonds.
Give this one a try later!
"You seem quite frightened right
Dry roasted almonds.
now."
Cinnamon applesauce. Decreased serum potassium.
Don't know?
5 of 135
Term
The nurse is planning care for a client with chronic kidney disease who
is a resident at a long-term nursing facility. The client is anuric and has
hemodialysis 3 times a week. Which intervention should the nurse
include in the client's plan of care?
Encourage intake of high potassium foods.
Provide perineal skin barrier cream.
Initiate toileting schedule.
Monitor for signs of anemia.
Give this one a try later!
